Insomnia (primary) in older people: non-drug treatments Search date May 2014 Cathy Alessi and Michael V. Vitiello ABSTRACT INTRODUCTION: Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia increases with age. Other risk factors include psychological factors, stress, daytime napping, and hyperarousal. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 14 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy for insomnia (CBT-I), exercise programmes, and timed exposure to bright light.

QUESTIONS What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)?. . 3 INTERVENTIONS NON-DRUG TREATMENTS IN OLDER PEOPLE Beneficial

Unknown effectiveness Exercise programmes . . . . . . . . . . . . . . . . . . . . . . . 10

Cognitive behavioural therapy for insomnia (CBT-I) . . 3

Timed exposure to bright light . . . . . . . . . . . . . . . . 11

Key points • Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia increases with age. Other risk factors include medical and psychiatric illnesses, psychological factors, stress, daytime napping, and hyperarousal. Primary insomnia is a chronic and relapsing condition that may increase the risks of accidents. It is chronic insomnia without specific underlying medical, psychiatric, or other sleep disorders. This review only covers primary insomnia in older people (aged 60 years and older). It examines evidence solely from RCTs and systematic reviews of RCTs. • Cognitive behavioural therapy for insomnia (CBT-I) improves sleep compared with no treatment. • Exercise may improve symptoms compared with no treatment, but evidence is weak. • We don't know whether timed exposure to bright light improves sleep quality compared with no treatment, as we found insufficient evidence. Clinical context

GENERAL BACKGROUND Insomnia affects up to 40% of older adults. The prevalence increases with age. Primary insomnia is chronic insomnia without specific underlying medical, psychiatric, or other sleep disorders.

FOCUS OF THE REVIEW Due to the high prevalence of insomnia in older adults, and the potentially increased risk of sleeping medications in this population, we chose to focus this review on the evidence for non-drug interventions for primary insomnia. In addition, essentially all published guidelines focusing on older adults include that non-drug interventions are recommended as first-line treatment for insomnia.

COMMENTS ON EVIDENCE The evidence for effectiveness of cognitive behavioural therapy for insomnia (CBT-I) is convincing, whereas the evidence for exercise programmes and timed exposure to bright light is less clear.

SEARCH AND APPRAISAL SUMMARY © BMJ Publishing Group Ltd 2015. All rights reserved.

.................... 1 ....................

Clinical Evidence 2015;05:2302

Sleep disorders

..................................................

The update literature search for this review was carried out from the date of the last search, December 2010, to May 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. After deduplication and removal of conference abstracts, 112 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 92 studies and the further review of 30 full publications. Of the 30 full articles evaluated, four RCTs were added at this update.

ADDITIONAL INFORMATION Although this review focuses on primary insomnia, it is important to mention that, in older adults, insomnia commonly occurs in the presence of other comorbid conditions and that CBT-I is also efficacious in treating such insomnia. DEFINITION

Insomnia is defined in the latest update of the International Classification of Sleep Disorders, third edition (ICSD-3) as repeated difficulty initiating sleep, maintaining sleep, or waking up earlier than desired, which is associated with daytime symptoms and which is not explained purely by inadequate [1] opportunity or circumstances for sleep. Additional types of sleep disturbance and daytime symptoms are included that occur primarily in children. This update of the ICSD also indicates that the sleep disturbance and associated daytime symptoms must occur at least three times per week. The latest update of the Diagnostic and Statistical Manual, fifth edition (DSM-5), defines insomnia disorder as dissatisfaction with sleep quantity or quality associated with difficulty initiating sleep, maintaining sleep, or early-morning awakening, which causes clinically significant distress or impaired functioning, despite adequate opportunity for sleep, and occurs at least 3 nights per week, [2] with some additional criteria. Both ICSD-3 and DSM-5 require a duration of (chronic) insomnia for at least 3 months. Since the ICSD-3 was published in 2014 and the DSM-5 was published in 2013, the studies included in this review generally used earlier versions of these or other definitions for insomnia. Primary insomnia has been defined as chronic insomnia without specific underlying medical, psychiatric, or other sleep disorders, such as sleep apnoea, depression, dementia, periodic limb movement disorder, or circadian rhythm sleep disorder. This review only covers primary insomnia in older people. For this review we define older people as aged 60 years and older (we included studies where at least 80% of participants were recorded as aged 60 years or older).

INCIDENCE/ PREVALENCE

One population survey in Sweden found that, across all adult age groups, up to 40% of people [3] have insomnia. A US survey in people aged 18 to 79 years found that insomnia affected 35% of all adults during the course of 1 year, and that prevalence increased with age, with estimates [4] ranging from 31% to 38% in people aged 18 to 64 years, to 45% in people aged 65 to 79 years. One US prospective cohort study in people aged over 65 years found that between 23% and 34% [5] had insomnia, and between 7% and 15% had chronic insomnia. It also reported a higher incidence of insomnia in women than in men.

AETIOLOGY/ The cause of insomnia is uncertain. The risk of primary insomnia increases with age and may be RISK FACTORS related to changes in circadian rhythms associated with age or the onset of chronic conditions and [6] poorer health as a result of ageing. Psychological factors and lifestyle changes may exacerbate perceived effects of changes in sleep patterns associated with age, leading to reduced satisfaction [7] with sleep. Other possible risk factors in all age groups include hyperarousal, chronic stress, [8] [9] and daytime napping. PROGNOSIS

We found few reliable data on long-term morbidity and mortality in people with primary insomnia. [10] Primary insomnia is a chronic and relapsing condition. Likely consequences include reduced quality of life and increased risk of accidents owing to daytime sleepiness. People with primary insomnia may be at greater risk of dependence on hypnotic medication, depression, dementia, and [11] falls, and may be more likely to require residential care.

AIMS OF To improve satisfaction with sleep; to prevent daytime sleepiness and improve functional and INTERVENTION cognitive ability during the daytime. OUTCOMES

Symptom improvement sleep latency; fragmentation of sleep/number of awakenings; early waking; quality of life; self-report of sleep satisfaction; sleep quality, measured by scales such as the Pittsburgh Sleep Quality Index (PSQI); performance on attentional task tests; daytime functioning measured by scales such as the Stanford Sleepiness Scale and the Epworth Sleepiness Scale; wake after sleep onset (WASO); sleep efficiency. Adverse effects daytime sleepiness during acute phase of treatment.

METHODS

BMJ Clinical Evidence search and appraisal May 2014. The following databases were used to identify studies for this systematic review: Medline 1966 to May 2014, Embase 1980 to May 2014, and The Cochrane Database of Systematic Reviews 2014, issue 5 (1966 to date of issue). Addi-

© BMJ Publishing Group Ltd 2015. All rights reserved.

........................................................... 2

Sleep disorders

Insomnia (primary) in older people: non-drug treatments

tional searches were carried out in the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment (HTA) database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were first assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted by an evidence analyst. Study design criteria for inclusion in this review were published RCTs and systematic reviews of RCTs in the English language, any level of blinding, and containing 20 or more individuals (10 in each arm), of whom more than 80% were followed up. There was no minimum length of follow-up. We included RCTs and systematic reviews of RCTs where harms of an included intervention were assessed, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table, p 16 ). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com). QUESTION

What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)?

OPTION

COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



For GRADE evaluation of interventions for Insomnia (primary) in older people: non-drug treatments, see table, p 16 .



The specific components of Cognitive behavioural therapy for insomia (CBT-I) varied across studies, but generally included stimulus control, sleep restriction, and cognitive therapy, with or without other components. However, some studies involved individual components of behavioural therapy, or other combinations of behavioural therapies for insomnia.



CBT-I improves sleep in older people with primary insomnia compared with no treatment. Benefits and harms

CBT-I versus no treatment: [12] We found five systematic reviews (search dates 2001 [although the review included some studies up to 2005]; [13] [14] [15] [16] 2002; and 2004 ). The reviews identified 11 RCTs in total. There was much crossover of reporting across the various reviews, with nine of the 11 RCTs reported in at least two of the reviews. All the reviews reported that the included studies demonstrated some improvements in symptoms with CBT-I compared with no treatment, [13] [14] although two reviews cautioned that the treatment effect was modest. Only two reviews performed meta[13] [16] [16] analyses, and we report only the results of the most recent review here. We also found six subsequent [17] [18] [19] [20] [21] [22] RCTs. Symptom improvement CBT-I compared with no treatment CBT-I is more effective than no treatment at improving sleep outcomes in older people with primary insomnia (moderate-quality evidence). Ref (type)

Population

Outcome, Interventions

Results and statistical analysis

Effect size

Favours

Sleep latency [16]

Systematic review

People aged at least 55 years 7 RCTs in this analysis

Mean time to fall asleep

Mean effect size –0.51

with CBT-I

95% CI –0.77 to –0.25

with no treatment

P

Insomnia (primary) in older people: non-drug treatments.

Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia ...
135KB Sizes 0 Downloads 5 Views